Plugged Milk Ducts 101

A plugged milk duct is pretty much what it sounds like: a blockage forms somewhere in the duct which prevents milk from flowing out towards the nipple. The milk then pools in that area causing lots of discomfort, pain, redness, swelling, hardness and anything else annoying. The only way to relieve it is to free the clogged area. Let's analyze this a bit.

They say that in order to prevent plugged ducts, the breasts must frequently be emptied. That ensures the passageways are free and clear for milk to pass through. Sounds fine. But plugged ducts can also be caused by the very nature of the milk. If milk is fatty it will clog faster. Makes sense, doesn't it? So someone like me is prone to clogged ducts because my milk is pretty fatty sometimes. It's not that I don't empty my breasts enough by feeding often.

They sound scary. Especially because online everyone warns you that if you do not treat the plugged duct aggressively (and immediately) then you will most likely get mastitis. I can assure you that I have never gotten mastitis from a plugged duct and I've had at least 50 plugged ducts. They often resolve with some basic care and most are gone within 24 hours or less. I'll walk you through a typical scenario.

It's 3:30 PM, just after my second pumping session at work, and I feel a bit of soreness on the inner edge of my left breast (90% of the time the plug was in that spot since they tend to come and go in the same area). By the time I come home from work I can feel real pain each time I press the area. I also see faint redness. Not like poison ivy red, but more like my boob is blushing.

Now. If I do nothing, Sam will not really enjoy eating from that side since the flow is obstructed and slower. More and more milk will pool up in the affected area. My breast will really hurt by nighttime. Tomorrow it will also be hurty.

However, here's what I do. At 3:31 I head to the bathroom at work and start to really give it to my boob. Using the heel of my hand, I press down from the top of my chest, down the affected side of the boob, and squeeze hard. It's supposed to hurt. Sometimes I'll be lucky and I'll see a white pinprick show up on my nipple right away, but other times it can take even a day to rear itself. That's the plug showing herself. I massage and squeeze (as if I'm hand expressing) and I can literally see a white piece of hardened milk pop out. Sometimes there is more than one milky clump. Often there's a few stringy strands of milk that follow. I keep massaging until nothing comes out anymore. With practice I have learned exactly where on my boob I need to press in order for milk from that specific duct to shoot out.

Some disclaimers:

• Sometimes I have to repeat the process again, so I do that after each nursing session. The area WILL feel sore after the plug is released but that clears away within a day or so. Additionally, milk will flow slowishly from that side, so your baby might not love nursing there. Always start with that side, and then hand express when you're finished nursing.
• The milk from the plugged area might also taste ickyish and salty (it has happened to me plenty of times - the milk also turned a weird shade of yellow). That's why it's common for the baby to stop nursing after a few moments because he's stopping once the milk starts tasting weird - which is when the older milk is coming down the chute.
• It often hurst to breastfeed from the affected side. This is because the area is firm and the baby cannot get a perfect latch - the shallow latch causes sore nipples.
• Sometimes you cannot release the plug via massaging. In such a case I take a hot shower and use a sterilized needle to prod the plug from below, in an outward motion (poking it inward just pushes the plug in further). You shouldn't be bleeding from this. To sterilize a needle, stick it through a flame until the tip turns red, and then rinse under cool water.
• They say to use heat either by showering or a heating pad, but I found none to be as effective as brute force of my hand massaging. The last 30 or so clogs that I had were treated solely with this method, and no heating element. 

If you catch it early, treat it early, and you'll save yourself a lot of discomfort. And having a clogged duct is a pretty good sign - for me, at least - that there's plenty of milk for the baby. In a way, I welcome these since it means I've got lots of milk!

Some like it hot, some like it cold

Sam has a very definitive taste when it comes to bottles. He will never take frozen milk that's been thawed in the fridge. Nor will he take frozen milk that's been rewarmed a second time. [update: since correcting the lipase issue and freezing immediately after expressing, Sam will take a bottle that's been rewarmed twice! So he doesn't have to finish his bottle in one shot anymore.] Now we know it's probably because of my excess lipase issue. He also likes his bottles really warm, even warmer than the temperature of milk when nursing, which is presumably 98.6 degrees or so. I wonder if that somehow masks the metallic/soapy taste caused by the lipase.

So I try to freeze my milk in two categories: full bottles like 4-5 ounces, and toppers of 1-3 ounces. This way, if I even think Sam might not want a full bottle, I try to have him take a smaller bag's worth so we don't waste so much milk. He will not take the leftovers a second time, only on random occasions, but I can't rely on that.

I don't have his bottle-taking habits down to a science because I'm not the one who actually gives him bottles. He wouldn't take one from - the last time we tried was when he was 2 months old, so who knows. Maybe he would drink from a bottle if I administered it. But there's really no need for me to give him one if I could nurse him. Sam only gets bottles at the babysitter, so she's the expert!

Letdowns

Letdowns are so weird. Usually the word signifies something negative and disappointing. But not when it comes to BFing. The word letdown brings breastfeeding mothers (and their offspring) much joy. Letdown is an easy laywoman's term for "milk ejection reflex", which is a complex, highly wondrous process that brings your milk to your baby. When the baby sucks your nipple, the nipple and areola become stimulated, which releases oxytocin (the "mothering hormone"). This causes contractions in the milk-making glands, literally squeezing them like a tube of toothpaste. The milk then shoots through the ducts on high-speed and baby enjoys the meal.

Now I never felt letdowns when nursing in the early days. I would feel random letdowns when it was on or around the time Sam would normally eat (say, 2-3 hours since last feeding). It would feel like an 18-wheeler riding over my breasts, and then my nipples would feel somewhat sore for a minute or two. I never felt this while nursing, though.

Only once my milk regulated at 3 months did I begin to feel them! About 30-60 seconds after Sam would actively start to suck, I'd feel that heavy feeling again and his sucking/swallowing pattern became steady and consistent. I'd still feel it randomly between feedings. Those were much more painful than the ones I'd feel while breastfeeding. On fuller days, I'd feel lots of these random ones, and the nursing ones would come really fast, only after a few seconds of sucking.

These days I feel letdowns most of the time, and they're not that obvious either. I usually have to focus on it in order to even notice it! I rarely get the between-feeds letdowns. On lower supply days I can't get more than one letdown per hour or so, even if I try nursing Sam two times in one hour.

I find that when pumping, I need to achieve about 3 letdowns to get 4-5 oz of milk - these days. In the past I'd get that all with one letdown. But when I nurse/pump I can only get one letdown. I don't know, I see lots of sites writing about keeping baby on the breast for longer so you can get more letdowns. I don't have that. While pumping, the initial letdown might yield only 2-3 ounces. So what do I do?

Here's how to achieve a manual letdown muuuuuch faster than using the stimulation mode on the pump. This is also great if you for some reason can't get a letdown and baby really wants to nurse already. Or if you're trying to bring baby back from a nursing strike and you want it to be appealing (i.e. milk already waiting for him at the table):

1. Try to relax. Right. Like pretend you're relaxed. Sit in a relaxing, comfortable position.
2. Start massaging both nipples at the same time - one with each hand. 
3. Try different moves to see which feels better to you: pinching, pulling, twisting, stroking, flicking, etc.  
4. Focus on what the letdown should feel like. Usually within 5 minutes you can get a letdown.
5. Enjoy the flow of milk.

For me, they are completely not psychological, but rather physical. I do not get letdowns by thinking of oceans of flowing milk nor when I look at pictures or videos of Sam (what lots of websites suggest). I can only cause myself to get them from direct stimulation, either from Sam's sucking, or from my hands. 

Green poops

Green poops that are frothy and liquidy are supposed to signify that your baby receives an unbalanced amount of foremilk and hindmilk during feeds.

Foremilk is the thin, light, sugary milk that quickly hydrates the baby and entices him to eat further. Hindmilk is the rich fatty stuff towards the end that looks whiter and heavier. Really, with each suck, baby is getting both foremilk and hindmilk, but the problem happens when the baby doesn't get enough time to nurse to really reach the hindmilk finale. So he fills up on foremilk. Which is FINE, according to my pediatrician. It has all that baby needs. But the green diapers are ewwy, I must say. And explosive.

I always let Sam stay on each side for as long as he wanted, yet he still had green diapers until 3 months of age. Seriously, they were never yellow, the color of choice. Still, the doctor wasn't concerned so I wasn't either, but I was curious to know why they were happening. I finally figured it out. I was making so much more milk that necessary that Sam got full before he even was halfway through the breast. It's not that I didn't let him stay on that side long enough. He just didn't need any more (though I had plenty of milk to go around).

When my supply regulated at about 3 months, the green diapers disappeared too.

Monthly Dips

Even though it happens all the time I am still not immune to it. I freak out when it happens. Sunday I nurse Sam just fine. He has plenty to eat. Monday at work I pump only a total of about 5-6 ounces or less, instead of my usual 9 ounces. My breasts feel soooo soft and empty. Sam needs to keep nursing at night, and the letdowns don't last very long. I don't hear as much swallowing when he is nursing. This is a sudden, drastic dip in supply, and I only recently noticed that these happen every single month!

When there's such a sudden drop, they say it's either because of stress, pregnancy, or the onset of a period. Well, these were never preceded by any particular stress, I took dozens of pregnancy tests which all showed negative, and I never got my period! So where on earth are these drops coming from?

I finally realized one day that they happen every month, sort of like a menstrual cycle. I went back to old emails of mine and chat logs and saw how I vented to friends about this around every 4 weeks or so. Interesting! Lately I began to get these drops together with other PMS symptoms.

In my period days (haven't had one since January 2013 so my memory of them isn't stellar, but I definitely remember some stuff), my labia would itch severely for two or three days before a period, and then mysteriously stop once the period started. So I had that again. Also extreme thirst. And a lower backache. Oh, and menstrual cramps. The real deal.

Only no blood. Yay!

After a few days (about 5-7) I'd see a sudden whoosh of milk. Like waking up in the night engorged type of sudden. Always on weekends. People tell me it's because I eat and sleep better over the weekend. I say it's because I don't need to pump!

Edited to add: I finally learned the reason behind my monthly drops in supply.

Fresh frozen and the excess lipase saga

Oxymoron? A scary thing happened to me, I freaked out, I worked to combat it, and it miraculously righted itself with an easy solution: fresh frozen.

Last week Monday Sam refused his normal amount of milk at the babysitter. He usually has a 5 oz bottle at around 11ish and then a 4 oz bottle at around 2-3. That day he had a total of 5 oz. Tuesday he did that again. Same with Wednesday. Each of those days he came home with the remainder of the milk in the bottle. It looked yellowish. I smelled it. I almost barfed. But milk smells, I've heard, so I daringly tasted a drop and BLECHEROO! It really tasted soapy and metallic. No wonder Sam turned it down. He has better taste than that. 

Turns out my milk has excess lipase. There are SO many articles out there that discuss it so I won't go into too much detail. But basically, everyone's BM has lipase, which is an enzyme that breaks down the fat so the baby can digest it. Usually this breaking down of lipase does not happen right away (I think it takes place inside the baby's body), but in some people, they have so much of it that the milk fat becomes broken down much quicker. Some people 4 hours later, some a day later, and some only find their freezer stash of one month old milk is bad. So it's really a unique situation for everyone.

What does one do about that? Some babies are totally cool with the yucky taste and drink the milk anyway. It's perfectly safe. Remember, the milk is just broken down, not spoiled. If baby will not drink it, don't blame him because it truly is yucko. The solution? Heat the milk (aka "scald" it) to 180 degrees and then quickly cool it before storing - this deactivates the enzyme and keeps your milk tasting delicious. That's such a pain, though, if you have to scald at each pumping session because your milk won't last the day in the fridge.

I decided to see how long my milk can "last" before it gets that ewwy taste/smell. I pumped a bit and put it in the fridge. After 4 hours it was fine. After 8 hours it already had a faint metallic taste. 24 hours later it's a strong metallic/soapy taste, plus it smells bad when heated. It didn't smell in the fridge when cold. 

Now this brought back to mind the early days when I went back to work. Sam did not take the bottle willingly at all. He would drink just an ounce or two and then another ounce or two a few hours later. He ate just to tide him over until he got hungry again. Poor boy. He did nurse well once at home and made up for it so I wasn't too worried. He was gaining weight as well. After about 3-4 weeks he would take a complete bottle. Now I think I know why. I'll bet that milk was also lipasey. In addition, Sam doesn't eat warmed up milk that slowly thawed in the fridge. Only milk that went straight from freezer to hot water. 

Later on he either A) got used to the taste and realized this is the situation and you gotta adapt, or B) the lipase was only really bad in the early days, which is common because there is more fat then or something. 

Well, now it seems to be bad again. Also lately I would freeze my milk only once I prepared the bottles for the next day - which was nighttime. Many hours after I'd pumped. So it was in the fridge during most of the day, slowly ickifying itself until the next afternoon when Sam would unwillingly drink just a bit. In the past I'd freeze the milk at work already, right after pumping - I don't know why. I just did that. Turns out that was the key to my solution.

I sent Sam some milk for this Monday that was scalded. He drank it beautifully. It also did not turn yellow, according to the babysitter. And the residue remaining in the bottle by the time he came home did NOT stink. On Tuesday I sent him with fresh frozen milk - milk that was frozen immediately after pumping - and he also drank it all really nicely!

Top: milk unaffected by lipase
Bottom: milk affected by lipase

So for now we are sticking with fresh frozen so I am spared the time-consuming task of scalding it each day. Freezing, I will dutifully point out, does cause some of the milk's important properties to be lost (scalding can also do that, btw), however it is MUCH better to serve this than formula. It's really of no health concern unless the baby only drinks frozen milk - we are talking just two bottles a day here, so no biggie.

Just a reminder: Milk that was affected by lipase activity looks yellower when thawed (but whiter when frozen), looks really fatty when warmed up, you can often see small globules of fat, it smells really bad, and has the taste of metal or soap. It IS safe to eat. The best thing to do if your baby is refusing bottles is to not blame it on the bottle - just taste the milk and you'll know for sure! Also, if you store milk for a freezer stash, defrost a bag every two weeks or so and make sure it tastes/smells fine.

Notice the picture on the left: The milk on top looks like milk should look when frozen. Pale yellow color, of even consistency. The bottom bag contains milk in which lipase already did its thing. You can see separate fatty sections and the milk is overall whiter and thicker looking.

I've been pumping for my baby (song)

(sing to the tune of I've Been Working on the Railroad)

I've been pumping for my baby
All his live long days
I've been pumping for my baby
Every day while I'm away
Don't you hear the clock announcing
Time to go pump again?
Can't you hear the momma shouting
Breastmilk, won't you flow?

Breastmilk, won't you flow?
Breastmilk, won't you flow?
Breastmilk, won't you flow some more?
Breastmilk, won't you flow?
Breastmilk, won't you flow?
Breastmilk, won't you flow enough?
Some days I can only pump one ounce
Some days the containers won't fi-i-i-ill
Some days there's no letdown reflex
Some days all the milk will spill
Drip drip drippity drip
Drip drip drippity drip-drip-drip-drip
Drip drip drippity drip
Dripping from the pump machine - oh yeah!
Don't you hear the momma crying
My little baby needs his milk!
Can't you hear the momma shouting
Breastmilk, won't you flow?

Something happened to my pump parts!
Something happened to my milk supply!
Something happened to my baby's latch!
Why, then, are my boobs so dry?
Drip drip drippity drip
Drip drip drippity drip-drip-drip-drip
Drip drip drippity drip

Dripping from the pump machine - oh yeah!